Lepromatous leprosy: An Unusual Presentation.

A 25 year old man presented with loss of sensations over both hands and feet and extreme difficulty in passing urine. On examination, an indurated sclerotic plaque was present on shaft of penis and scrotum in addition to other features of lepromatous leprosy. Skin biopsy from the penile lesion showed presence of a large number of acid fast bacilli with a BI of 6+ extending into the epidermis and histopathology showed absence of Grenz zone and presence of foamy macrophages in the dermis up to the dermo-epidermal junction.

Study of different methods of susceptibility testing of M. tuberculosis.

This communication is on a multi-centre collaborative study carried out by New Delhi Tuberculosis (NDTB) Centre, Delhi, to compare the different methods of drug susceptibility testing (DST) of Mycobacterium tuberculosis for Streptomycin, Rifampicin, Isoniazid and Ethambutol in various accredited laboratories 40 samples (selected by simple random sampling technique) from sputum positive out-patients presenting between December 2004 and January 2005 were collected at New Delhi Tuberculosis Centre from 24 males and 16 females (age ranging from 18 to 55 years) were taken up for culture and susceptibility testing. The proportion method of DST done at NDTB Centre was taken as standard for comparing the other methods after it was found to have a good agreement with the proportion method performed at Tuberculosis Research Centre, Chennai (Kappa coefficient 0.75 to 1). All 40 sub-cultures were processed for DST by the resistance ratio and proportion methods at NDTB Centre. Also, the 40 sub-cultures were sent to Central JALMA Institute for Leprosy (JALMA), Agra that used the resistance ratio method and 25 sub-cultures were transported to National Institute of Communicable Diseases (NICD), Delhi for performing the Bactec 460TB method. The resistance ratio and proportion methods were compared both intra-laboratory (NDTB Centre) and inter-laboratory (NDTB Centre and JALMA). The sensitivity and specificity of the resistance ratio method compared to the proportion method both inter and intra-laboratory, were very high for all the drugs (except Ethambutol inter-laboratory). This was corroborated by the good agreement between the resistance ratio performed at the two centres. Bactec 460TB method, on the other hand, did not have acceptable measures of validity (sensitivity and specificity) compared to the proportion method for Streptomycin and Ethambutol. Both resistance ratio method & proportion method are comparable and either can be used for making clinical decisions. But Bactec 460 method, despite yielding early results loses out on validity.

Lymphangioleiomyomatosis: a rare cause of breathlessness.

A 24-year-old female presented with complaints of cough with scanty expectoration, breathlessness on exertion and chest pain for the last three years. These symptoms had appeared during the 12th week of her third pregnancy. She was given anti-tuberculosis treatment at another hospital for nine months without any improvement in symptoms. Four years ago she had been diagnosed to have leprosy of borderline variety for which she had received treatment. On examination, she was tachypnoeic with a respiratory rate of 33 breaths per minute. She had clubbing and small, discrete and firm lymph nodes in the anterior cervical region. Chest examination revealed wheezing with bibasilar end-inspiratory crepitations.

Topical phenytoin suspension and normal saline in the treatment of leprosy trophic ulcers: a randomized, double-blind, comparative study.

OBJECTIVE: To evaluate and compare two strengths of topical phenytoin sodium suspension (2% and 4%) with normal saline in the healing of acute trophic ulcers in leprosy patients. METHODS: A prospective, parallel, double-blind, randomized study was conducted in 45 leprosy inpatients with acute trophic ulcers. Patients were randomized to receive 2%, 4% or normal saline dressing on their ulcers once daily for 4 weeks. Efficacy parameters such as a reduction in the surface area of the ulcer, bacterial culture of the ulcer swab, appearance of healthy granulation tissue, cessation of ulcer discharge and overall gradation of clinical healing and safety were assessed at weekly intervals. RESULTS: The ulcer area reduction was greater in the 2% and 4% phenytoin groups compared with the normal saline group (p<0.001). Appearance of healthy granulation tissue and cessation of ulcer discharge was also observed earlier in the two phenytoin groups. At the end of 4 weeks, 11 ulcers each had healed completely in both the 2% and 4% phenytoin groups compared with none in the control group. There were no statistical differences between the 2% and 4% phenytoin groups. No side effects were reported by any patient. CONCLUSION: Topical phenytoin appears to be an effective, safe and cheap therapeutic option for the healing of trophic ulcers in leprosy patients.

Radiological and antroscopic study of maxillary antrum in multibacillary leprosy patients.

Sixty consecutive patients having multibacillary leprosy were examined for symptoms of nasal involvement and sinusitis. A complete ENT examination was carried out of all these patients and they were subjected to radiological examination of paranasal sinuses. Radiological abnormalities of maxillary antrum were found in 15 of 20 cases of lepromatous leprosy, 6 of 26 cases of borderline lepromatous and in 14 cases of mid-borderline leprosy. Localized or generalized mucosal thickening was the most common finding, followed by opacity of maxillary antrum. Radiological abnormalities were confirmed by antroscopy, which is the most appropriate technique for making an accurate diagnosis of maxillary antral diseases. Initially, antral involvement may begin with a localized area of mucol erythema, progressing to a typical granuloma formation and ulceration. The antero-inferior part of the antrum was found to be the most commonly affected region.

Reinvestigation on the causes of genomic GC variation between the orthologous genes of Mycobacterium tuberculosis and Mycobacterium leprae.

Genomic GC (overall G+C content of the coding sequences) variations were reinvestigated between the orthologous genes of Mycobacterium tuberculosis and Mycobacterium leprae species. It was observed that overall genomic GC variation between the species mainly originates from the combined effects GC(1) and GC(2) variations. But codons having identical amino acids with different codons (IA) (between the orthologous codon pairs) are responsible for the genomic GC(3) variation between the organisms, whereas orthologous codons having different amino acids (DA) between the two organisms are responsible for the variation of GC(1) levels. Further analyses indicate that duets and quartets are going in the same direction with same magnitude in changing the GC(3) levels for IA category, whereas GC(1) levels of duets of DA category decreases significantly from the overall GC(1) levels but GC(1) levels of quartets increases significantly from the overall GC(1) levels. GC(3) levels of informational genes for the IA category decrease more rapidly than the other functional categories of genes. The biological implications of these results have been discussed in this paper.

Fever due to levamisole.

Fever is rarely caused by levamisole. We report a 26-year-old woman who repeatedly developed fever 4-12 hrs after taking levamisole. The association was confirmed by repeated provocation tests.

Utility of fine-needle aspiration cytology in the classification of leprosy.

The role of fine-needle aspiration cytology (FNAC) in the diagnosis of benign skin lesions has been restricted primarily to the evaluation of bacteriologic and morphologic indices in leprosy. This study was undertaken to evaluate the efficacy of FNAC in the diagnosis and classification of lepromatous lesions. Aspirates of 94 newly diagnosed cases of leprosy were studied, and the bacterial load was determined by modified Ziehl-Neelsen (ZN) stain. A skin biopsy was taken from the same site at the same sitting. Frozen and paraffin sections stained with hematoxylin-eosin (H&E) and ZN stains were examined from the biopsy specimen. In 61 of 94 cases (64.9%), the aspirates were satisfactory. Both diagnosis and classification of leprosy were possible in 40 of these 61 cases; the rest of the aspirates showed nonspecific chronic inflammation. The 39 cases of leprosy where a biopsy was available from the same site were classified on FNAC into tuberculoid (TT and BT), lepromatous (LL and BL), and midborderline (BB) subtypes. Taking the histologic diagnosis and Ridley-Jopling classification to be the gold standard, a strong concordance in tuberculoid leprosy cases (18 of 20 cases, 90%) and in lepromatous cases (15 of 16 cases, 93.7%) was observed. Midborderline cases of leprosy posed a problem, and a correct cytohistological correlation was observed in only one of the three cases.

Aplasia cubs congenmta associated with meningomyelocoel.

Aplasia cutis congenita is a rare congenital anomaly where skin is missing over part of the body. Most of the cases are present on the scalp. We present a case of ACC where skin was absent over the lumbosacral area. It was associated with meningomyelocoel.

Clinico-histopathological concordance in leprosy.

Histopathological examination of biopsies from 111 patients with clinically diagnosed leprosy was carried out in order to observe the clinico-histopathological correlation. Clinical diagnosis was based on Ridley and Jopling (R-J) classification and World Health Organization (WHO) classification. The concordance rate between the two clinical classifications was 73.8%. Sections were stained with haematoxylin and eosin (H&E) and Ziehl-Neelsen's (Z-N) stains. The histological classification was as per the R-J criteria. Skin biopsy showed evidence of leprosy in 104 cases (93.69%). Overall concordance was observed in 58.6% (R-J) and 85.6% (WHO classification). The kappa test, when applied, showed significant agreement between clinical and histopathological diagnosis (z=11.775; P<0.001). Individual subtypes showed variable concordance rates which were again higher using WHO classification. When some of the subtypes were combined, the concordance rate was 83.02% for TT+BT; 72.58% for BT+BB+BL; 73.91% for BL+LL; 80.77% for BL+HL and 100% for LL+HL. (See Introduction for definitions of abbreviations.) The present study highlights the importance of histopathological examination for exact subtyping of leprosy, so as to facilitate the institution of accurate mode of therapy and regular follow-up of patients to prevent undesirable complications.

Keratoacanthoma Arising in an Organoid Nevus (nevus Sebaceous).

Organoid nevi may rarely be complicated by development of keratoacanthoma. We report a 21-year old man who presented with a hyperkeratotic papule developing over a well demarcated hyperpigmented irregular plaque on the forehead. Histopathology revealed features suggestive of keratoacanthoma developing in a lesion of nevus sebaceous. Literature search revealed 11 such reported cases. Most of the reported patients were young and had lesions on the face. Such lesions should be excised completely to prevent any malignant change in the future.

Naevoid psoriasis.

A 6-year-old male child had linear scaly erythematous band on the penis, undersuface of penis, extending to the scrotum since birth. He was diagnosed clinically as well as histopathologically as a case of naevoid psoriasis.

Atypical multicentric reticulohistiocytosis.

A 38-year-old male had arthritis since 8 years and erythematous papules, plaques, cutaneous and subcutaneous nodules over face, ears, trunk, and extensors of arms since 2 years, Histopathologically, presence of multiple foreign body giant cells confirmed the clinical diagnosis of multicentric reticulohistiocytosis. Unusual associations were: tapered fingers with depressed scars on their tips, low ESR - (5mm 1st hour). Raynaud's phenomenon and exaggeration of lesions after methotrexate.